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152-178 Iris Ln Tt/,I �:� DAVIE COUNTY HEALTH DEPARTMENT � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION a *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name d U��_ � (�c Date _j N2 5252 Location �..� Subdivision Name � S"-) Lot No. Sec. or Block No. q . Lot Size - 1 House Mobile Home _� Business Speculation No. Bedrooms 2)" No., Baths � No. in Family Garbage Disposal YES ❑ NO .lam Specifications for System: t <. Auto Dish Washer,, YES,UTA NO ❑ U(3 r, - Auto Wash Machine YES ©/ NO ❑ Type Water Supply 9J J 1_5 *This permit Void if sewage system,described fbelow is not-installed within 36 months from date of issue. 0 16 Improvements permit'by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by16-0 1 J'b� Qoi r, F Certificate of Completion (�S Date "The signing of this certificate shall indicate that the system describdd above has been installed in compliance with - 9 9 Y p e the standards set forth in the above regulation, but shall in NO way be as a guarantee that the system will function satisfactorily for any given period of time. Y , APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department21 Environmental Health Section / P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Reque ted By. / 4016 .10/1 Business Phone 70V e-f L 439,E 2. Address � .-2 //7'? Z 9 CIE= ZZ ,A 3. Property Owner if Different than Above Address 4. Permit To: a) Install Iter Repair //-- b) Privy Conventional Other Type 1��S T�� 7_AAbCJ Ground Absorption c) Sub-Division Sec. Lot N� 5. System used to serve what type facility: House Mobile Home_ ome Business _ IndustryOther ✓-Dou f3bE int h{_ PCA-Cf�b D& 4645,6.441 r-- b) Number of people 6. 4 If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms—Bath Rooms—Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, eta Estimate amount of waste daily (24 hours) 7. Number and type of water-using fixtures: commodes urinals garbage disposal lavatory 91 showers washing machine a dishwasher sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes Nom 9. a) Property Dimensions - • 9 OW Ae/7.�:-_ b) Land area designated to building site c) Sewage Disposal Contractor ¢'�Y�Yf -� 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? ye What type? Z This is to certify that the information is correct t e best of my knowledge. 7' s —A Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions �to/property: X1,1 �� �1�1/�� �r� ���✓ r%G ltiro .b�� . B�s��� �. 7'0 WL (,J' DCHD(6-62) t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 S SOIL/SITE EVALUATION Name s��+ ?c\ "' Date -1 `6 Address er -;� Lot Size FACTORS ARE� AR AREA 3 AREA 4 1) Topography/Landscape Position S S ciF:;' PS PS U U U 2) Soil Texture (12-36 in.) Sandy, S S Loamy, Clayey, (note 2:1 Clay) Pj PS US US �a 3) Soil Structure (12-36 in.) S S Clayey Soils P (& PS PS U U U 4) Soil Depth (inches) S S P PS PS C U U U 5) Soil Drainage: Internal S S SdD PS PS U U U U External ---�� S S 66PS �J PS PS U U U 6) Restrictive Horizons �1 ------------ 7) Available Space S SS PS PS U U U 8) Other (Specify) S S S S PS PS PS PS U U 9) Site Classification U—UNSUITABLE S— LE PS rovisionally Suitable Recommendations/ Described by - Title �� Date SITE DIAGRAM DCHD(6.82)